Cox-MAZE IV with Coronary Artery Bypass Graft (CABG) and Mitral Valve Replacement (MVR)

1. Introduction

2. Incision

1. Perform Median Sternotomy

3. Left Mammary Artery Harvest with Skeletonization Technique

1. Expose the Chest Wall
2. Identify the Left Internal Mammary Artery
3. Expose the Internal Mammary Artery
4. Heparinize
5. Divide the Conduit
6. Place a Bull-Dog at the End of the Artery

4. Preparation for Bypass and MAZE

1. Expose and Open Pericardium to Access the Heart
2. Suspend the Edges of Pericardium
3. Perform Aortic Ultrasound
4. Synchronize Cardio-Version
5. Place Purse-String Sutures
6. Mobilize Superior Vena Cava

5. Cardiopulmonary Bypass

1. Cannulate the Aorta
2. Connect the Aortic Cannula to the Bypass Machine
3. Cannulate Superior and Inferior Vena Cavae
4. Connect Bicaval Cannulas to Venous Limb of Pump
5. Go on Pump

6. Cox-MAZE IV

1. Isolate Right Pulmonary Veins En-Bloc Using Bipolar Radiofrequency Energy
2. Ablate Right Pulmonary Veins Circumferentially
3. Open the Right Atrium
4. Use Bipolar Radiofrequency Clamps to Create Right Atrial Lesion
5. Use Cryoprobe to Create Right Atrial Lesion
6. Close Right Atrium
7. Use Cryoprobe to Create Left Isthmus Lesion
8. Isolate Left Pulmonary Veins
9. Create Left Atrial Lesion

7. Coronary Artery Bypass Grafting

1. Assess LIMA
2. Identify and Assess the LAD
3. Perform End-to-Side Anastomosis

8. Mitral Valve Replacement

1. Perform Left Atriotomy
2. Excise Anterior Leaflet of Mitral Valve
3. Size the Valve
4. Lower Connecting Lesions (MAZE)
5. Create Left Isthmus Lesion (MAZE)
6. Create Roof Lesion (MAZE)
7. Place Interrupted, Everted, Pledgeted Mattress Sutures
8. Give Cardioplegia
9. Implant Valve
10. Tie Down Sutures
11. Close Left Atriotomy

9. Wean from Cardiopulmonary Bypass

1. Place AV Pacing Wires
2. Start Temporary Pacing
3. Go Off Pump
4. Decannulate

10. Closure

1. Ensure Hemostasis
2. Place Sternal Wires
3. Close Subcutaneously
4. Close Superficially with Staples

11. Post-op Remarks